When we learned to listen: The legacy of Elvin Semrad
Over more than three decades of writing this column, from time to time, I have quoted Dr. Elvin Semrad whom I briefly described as “the late Boston psychoanalyst.” I supposed he needed no further introduction because of his legendary stature in the psychoanalytic community that was synonymous with psychiatric and psychological teaching and practice in twentieth century Boston.
As a product of that educational system, I assumed my readers were familiar with the same luminaries who guided my own development as a psychologist. But 30 years is a long time, so maybe you knew of Dr. Semrad, and maybe you didn’t. In any case, let me introduce him now.
The time between Dr. Semrad’s day and our own has seen the development of a wide variety of evidenced-based therapies targeted toward specific diagnoses and symptom clusters.
Cognitive behavior therapy has been a game changer with its modifications to address an ever-expanding array of conditions including but not limited to borderline personality disorder, post-traumatic stress disorder, and psychosis. Add to all this what we have learned about the biological basis of major mental illness and the development of safer and more effective pharmacological treatments.
If the timespan between then and now were a landscape, we have traversed a continent, carrying with us the best of every place we stopped along the way.
Somewhere near the beginning of our journey, we learned to listen. And if you were lucky enough to learn from Dr. Semrad, even if only by attending some of his case conferences, you will never forget the Nebraska farm boy who grew up to be the pre-eminent psychoanalyst and teacher in the halls of Harvard psychiatry.
Elvin Semrad was born in Abie, Nebraska in 1909. He graduated from Peru State Teacher’s College, went to the University of Nebraska Medical School, interned in psychiatry in Omaha, and did his residency at the Massachusetts Mental Health Center. He completed his analytic training at the Boston Psychoanalytic Institute after an interruption for military service during World War II and remained in Boston. Dr. Semrad worked for six years teaching residents at Boston State Hospital and then became clinical director at the Massachusetts Mental Health Center.
When I started my internship at Mass Mental in 1971, our training director encouraged us to attend as many of Dr. Semrad’s case conferences as we could. In rooms crowded with staff, psychiatric residents, psychology interns, and other students, Dr. Semrad presided, a portly, white-haired, mustached Santa with his dark-rimmed glasses, his pipe in his left hand and his cheek resting in the palm of his right. He radiated a calm benevolence and genuine interest like the grandfather we all wish we had. After the patient’s doctor presented the case, the patient entered the room and Dr. Semrad conducted his interview. Before the patient left at the end of the interview, Dr. Semrad asked his permission to talk with his doctor and the “young people” present about the patient’s problem and then proceeded to give his impressions and recommendations.
Dr. Semrad spoke plainly and simply to the patient and staff, using common metaphors from daily life and from his early days on the farm. He was also a master of scholarly writing and authored or co-authored more than 200 papers, but those who knew him well observed that he always seemed most himself when talking to patients, staff, and students.
In his interviews with patients, he listened with his eyes as well as his ears, looking always for signs of the body telling the truth about the patient’s struggle when the words served only to obfuscate and avoid. A blush, a tic, a blink of the eye, all were signs of the autonomic nervous system demanding to have its say.
To a patient who just lost his job or his lover, Dr. Semrad would ask, “Where does it hurt?” He kept at it until a locus could be identified or the patient became too tired or confused to reply. That rarely happened because in conversation with a therapist who clearly meant business, often enough the mute spoke and the confused became momentarily clear enough and brave enough to hazard even a sidelong glance at the unresolved issue that brought them into the hospital.
When he sat with a patient or a therapist, Dr. Semrad meant business. In a firm but always respectful way, he reminded us of the importance of personal responsibility – the responsibility of the patient to figure out what he wanted to do with his life and the responsibility of the therapist to help him get there.
In his deceptively simple way of putting it, Dr. Semrad said, “There is only one mental illness and that is self-deception. And people deceive themselves about only two things, loss and failure.” There was plenty of loss and failure at Mass Mental as there is in any psychiatric hospital.
The first goal of treatment, according to Dr. Semrad, is to help the patient acknowledge the precipitating event that disturbed the delicate balance of his psyche and deal with the affect it aroused. On feelings, he said, “First they have to be acknowledged, then one has to bear them, and finally one has to decide what to do with them.” Therapy heals in part because it’s easier to bear painful feelings together with a trusted companion, and that companion is the therapist.
Dr. Semrad spoke in aphorisms. Like the Buddah, Confucius or a Zen master, he was a font of wisdom that he expressed in a few well-chosen words. When Dr. Semrad spoke, you took notes whether you were one of his psychiatric resident supervisees or an attendee at his case conferences. No one had to tell you what he was saying was important. You just knew, and you had to write it down.
After Dr. Semrad’s sudden death at age 67 from a heart attack, two of his former residents, Dr. Susan Rako and Dr. Harvey Mazer, collaborated on a book of his quotations, “Semrad: The Heart of a Therapist.”
The book is a treasure trove of Semradian wisdom in 206 pages divided by topic into 26 chapters. In the Introduction, Dr. Mazer writes that he had the idea for such a book as he was leaving his residency and mentioned it to Dr. Semrad. He responded, “I hope you will take away with you what you found valuable, use it, and pass it on. As for the rest, throw it away!”
Elvin Semrad was a gifted teacher but he was not without his shortcomings, and his humility told him that not everything he taught would be valuable. Even so, he taught us how to listen, how to talk with people about what is most important to them, how to help them bear the sadness in their lives, and stay focused on the work of therapy. By his example he reminded us to be always respectful and humble. And so in the spirit of Dr. Semrad’s parting words to Dr. Mazer, I am happy to pass on to you some of the highlights of what I have found valuable and used in the work of this remarkable guide.